Healthcare Provider Details

I. General information

NPI: 1821421546
Provider Name (Legal Business Name): ORTHOPEDIC AND SPORTS REHABILITATION PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7872 CENTURY BLVD
CHANHASSEN MN
55317-8005
US

IV. Provider business mailing address

7872 CENTURY BLVD
CHANHASSEN MN
55317-8005
US

V. Phone/Fax

Practice location:
  • Phone: 952-448-9088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2365
License Number StateMN

VIII. Authorized Official

Name: BENJAMIN COLLIN
Title or Position: ATHLETIC TRAINER
Credential:
Phone: 952-512-2400